The Evaluation of the Family Nurse Partnership Programme in Scotland: Phase 1 Report – Intake and Early Pregnancy

5 PREGNANCY

This chapter describes the contacts between clients and their Family Nurse during the pregnancy phase of the programme. The findings reported here are primarily based on the first qualitative interviews with Family Nurses and clients (interviewed during their pregnancies, prior to the 40 ^th week), as well as some monitoring data on visits completed by late October 2010. As discussed in chapter 4, the qualitative interviews reflect clients' and family Nurses' perceptions and understandings of these contacts and may not necessarily always agree with each other.

5.1 The visiting schedule

FNP has a clearly defined schedule of home visits to clients. The frequency, structure and content of visits required in order to implement the programme according to the Core Model Elements and fidelity 'stretch' goals are closely specified in the FNP Home Visit Guidelines. The aim is to ensure that clients receive the guideline "dosage" overall and in relation to specific key domains (see below), both during pregnancy and after the child is born (see Appendix E for a full list of the Core Model Elements and fidelity 'stretch' goals). Again, these specifications are based on 30 years of research in the USA on the most effective way of structuring the home visiting programme.

Adherence to this structure, content and process is essential to achieving fidelity to the model.

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At every visit, a Home Visit Encounter Form is completed by the Family Nurse. This includes the date, time and length of the visit. It also records the client's reaction to the materials used in the session, the topics covered and any referrals to other agencies. The schedule of visits is intended to be weekly for the first four weeks and fortnightly thereafter until the baby is born. The materials which the Family Nurses use in their visits cover 14 visits. However, this is based on enrolment by 16 weeks and a full term birth, but could not be achieved for enrolment at 28 weeks. The fidelity 'stretch' goal for pregnancy is all clients receive at least 80% or more of expected visits.

There are clear guidelines in relation to the topics to be covered during the pregnancy period visits. The fidelity 'stretch' goals also specify what proportion of time should be spent on each of five programme domains in this period. ¹² The five domains covered by the fidelity 'stretch' goals are: personal health, maternal role, life course development, family and friends and, finally, environmental health. For each domain, there is a guideline in relation to "dosage". For example, during pregnancy approximately a third to two-fifths of time is meant to be devoted to personal health and a quarter to maternal role. Within each domain, there are numerous separate topics and associated material, which are delivered at the relevant point in the pregnancy, although this may vary for individual clients.

Final measures for the pregnancy period relating to adherence to the recommended 'dosage' of visits (see Appendix E) are not included in this report, but will be included in the late pregnancy/early infancy report. However, we are able to report on client and Family Nurse perceptions of the visiting schedule and its acceptability in the early stages of clients' involvement with the programme.

Clients regarded the initial weekly contacts at the start of the visiting schedule as a way getting to know the Family Nurse - the shift to fortnightly visits thereafter was felt to be appropriate. The fortnightly visits clients were experiencing at the time of their first qualitative interviews were described as "just right, it's not too much, just perfect"Pregnancy Interview, Client 9] and were seen to give clients time to think about any questions or worries they may have which they might want to discuss with their Nurse at the next scheduled visit. The visiting schedule seems, therefore, to match clients' shifting needs over the course of their pregnancy.

Clients reported that visits generally lasted between one and two hours, but this varied depending on the topic that were being discussed and the stage in their pregnancy. All of the clients interviewed felt they had enough time with their Family Nurse. They also felt that if they needed more time to talk about something they could ask and the Nurse would, if possible, stay longer. Although there were clients who reported initial concerns that they may not have any questions for the Nurse, this fear seems to have dissipated once the Nurse started to talk to them and they became involved in the discussion. This may be an example of how the Family Nurses' use of motivational interviewing techniques ¹³ helped clients to participate meaningfully in the programme.

Appointments for the subsequent visit were made at the end of a contact. Clients reported that they found it helpful to have a note on their folder both of the time of the next appointment and of topics they wanted to discuss. Family Nurses were reported as being very flexible, particularly for clients who were in employment, arranging appointments first thing in the morning or last thing in the afternoon. A further indicator of the developing relationship between clients and their Family Nurse was clients' expression of a clear preference to see their own Family Nurse rather than someone who they "did not know and who did not know them", even if this meant there was a gap between visits because of a Nurse's illness or annual leave.

All clients reported that they had mobile telephone contact details for their Family Nurse or for the Supervisor. The extent to which clients had contacted their Nurse outwith the visits varied greatly. Some clients had never contacted their Nurse by telephone, although they stressed that they felt they could if necessary, but had simply not needed to do this. Some had contacted their Family Nurse once or twice, while still others indicated that they had contacted their Nurse by telephone or text frequently. These clients expressed concern that the Nurses "must get quite annoyed" about frequent or untimely contacts, but also commented that they may not get an immediate response from the Nurse. They appreciated that their Family Nurse would always respond, even if it was not immediate and they valued the between-session reassurance that a conversation with their Nurse provided if they had a question or were worried.

If I was ever worried I would always ask her and she's always there.

[Pregnancy Interview, Client 1]

The Family Nurses found certain aspects of the pregnancy programme easier to deliver than others. In particular, they described the challenges they faced in relation to helping clients achieve their life goals. They described a "facilitator" (these are materials on a wide range of topics that Family Nurses can use in their discussions with clients to promote discussion) early in pregnancy that allows clients to establish their future goals, but the discussions were not necessarily ones that happened every week. The Family Nurses described delivering the programme in the early stages of clients' pregnancies in very positive terms - they felt that clients particularly looked forward to their visits early on:

I think the weekly visits at the beginning are ... are fantastic. …They really like it. They're looking forward to you coming (...) because they're excited about their pregnancy, and, at the beginning, they often don't really feel that pregnant, and also they've got very few midwife appointments and things at that point.

[Family Nurse 3]

In terms of the delivery of the pregnancy materials, Nurses felt that those clients enrolled early in the recruitment phase would have experienced a very different style of delivery to those clients enrolled later. It was recognised that as they became increasingly familiar with the materials, the Nurses became more confident with their delivery:

…the sort of 21st, 23rd, 22nd, 23rd, 24 ^th client have a very different experience of me delivering the programme than the, you know, girls 1 to 4, 1 to 10…because you're increasingly familiar with the material and how best to deliver said material, or I don't know 'how best', but hopefully you get better at it.

[Family Nurse 6]

Certainly, over time, the Family Nurses appear to have become increasingly confident in their delivery of the pregnancy materials (reflecting similar findings from Barnes et al's evaluation of the first 10 pilot sites in England). There were a number of reasons why they felt that this could be the case: growing familiarity with programme material; greater feeling of competence in delivering the material; and a greater knowledge of 'what is coming next' in the programme.

At the time of the Nurse interviews, some clients had already given birth and the Family Nurses were experiencing again the anxiety and lack of confidence associated with the delivery of new materials relating to the infancy phase of FNP. Additional training was not seen as a solution, but rather gaining familiarity with the materials through practice and discussions with colleagues. The support provided by the Family Nurse supervisor - including the joint client visits where the Supervisor accompanies each nurse - also appeared to be highly valued (see further discussion in Chapter 7). However, there were suggestions that the opportunity to observe materials being delivered by an experienced practitioner might have been helpful. Moreover, while they acknowledged that experience of the programme enhanced their confidence, the Family Nurses suggested that lack of time inhibited opportunities to share learning within the team in relation to specific elements of programme implementation.

Nurses felt that the frequency of client visits was appropriate - as indicated earlier, they felt clients appreciated the weekly visits, and the Family Nurses also viewed these as helpful in building relationships with clients early on in their involvement in the programme. However, as discussed in section 4.3.4, there was a feeling that the speed with which clients were engaged with and enrolled to the programme in the recruitment phase added considerable pressure to their workloads at the beginning of the programme.

Family Nurses suggested that in order to keep up with the programme during the early phase of delivery, they had to make contact, on average, with four or five clients per day. In addition to time spent directly with clients, home visits also involved travel and preparation time. Nurses commented that the programme's Edinburgh City-wide catchment area meant they spent a considerable amount of time travelling between clients. While the Supervisor attempted to match clients and Nurses within geographic locations and the Nurses themselves attempted to cluster their client visits, this could easily break down: clients might cancel appointments or request alternative dates and times, which sometimes resulted in travelling from one end of the city to the other in order to achieve the required client contacts. Moreover, clients did not necessarily stay in the same area and might re-locate to a different part of the city - so the geographic spread of each Nurse's caseload did not necessarily remain the same throughout the programme.

Nurses also reported spending time preparing for each client visit. Early on, given that the Nurses were all new to the programme, this was perhaps inevitably time consuming. As they became more experienced, preparation time may start to feel less onerous. However, where Nurses had a high proportion of particularly vulnerable clients they reported that this involved considerable additional work in terms of liaising with external agencies, including case discussions with the Supervisor and, in some cases, a child protection advisor.

The final layer impacting on Family Nurses' workloads was the paperwork to be completed for each client visit - the Home Visit Encounter Form - plus any other assessments that might have been carried out in the course of a visit. In addition to the demands on their time outlined above the family Nurses also had weekly, fortnightly and monthly supervision sessions. As a result, although the Family Nurses understood the reasons FNP had been established around tightly specified fidelity criteria, they also described delivery of the early months of the programme as feeling at times like an "impossible task" in terms of the level of work required to deliver the programme with fidelity to the original model. Thus while Family Nurses attempted to keep their clinical contacts within working hours, it was clear that preparation and travel time for visits (and training) extended their hours beyond the standard working day.

Family Nurses stressed that they were well looked after by the Supervisor and they reiterated that they were strongly encouraged to take time back and to be mindful of the amount of hours that worked. They acknowledged that they had contributed to their own work pressures, but this was perceived to be because of their dedication and commitment to support their clients.

We want to be there for the girls, so therefore yes I am doing a huge amount of hours, but it's through my own pressure"

[Family Nurse 3]

5.2 The content of contacts

As discussed above, the content of each FNP visit at each stage of the programme is carefully defined, with a range of supporting materials that can be used with the client. However, while there is an imperative to deliver the programme with fidelity in terms of visit structure and content, the Family Nurses do not disregard immediate or pressing concerns a client may have which may not necessarily be on the agenda for that visit. Similarly, at an early stage in the programme, Nurses work with each client to "agenda match" the programme's goals with the client's own life goals.

Clients' perspectives were very much that their Family Nurse worked with them to decide what was talked about and regarded their Nurse as flexible. In some cases, clients felt that the visits were very much set, but were happy to "stick" with that if they did not have any specific topics, questions or worries or simply felt that the programme reflected their needs at any given time. Others believed that they always decided what they wanted to talk about. This might be something that they had been discussing with their partner between visits, or something that been concerning them ( see section 5.2.2 for Family Nurses' accounts of their attempts to match the programme's and their clients agendas). Clients commented that that if they had a lot of questions or worries about a particular topic that was not necessarily scheduled for that visit, this would be brought forward by the Nurse so that the client's questions or concerns could be answered. Clients were aware of their Family Nurse looking at the list of topics and commenting 'I don't think this is for us'. The clients' perception was that Family Nurses were able and willing to be guided by them, tailoring their input to the client's needs.

Clients felt they had enough time for each topic and that if they wanted to talk more about something or still were not sure about a topic, they could ask to talk more at the next visit or, if necessary, request an additional visit. Clients felt they had been told everything at the right time and reported that they knew everything they felt they needed to at the time of their first qualitative interview.

Topics covered are] fab. They're all stuff like I had in my mind, like that I was going to ask her. They're great. They cover everything I need to know.

[Pregnancy Interview, Client 13]

The Family Nurses' accounts of their contacts with clients corroborate the clients' in terms of agenda matching. This is an area in which the Family Nurses, by their own accounts, have become more adept at over time as their familiarity with FNP materials has improved. For example, Family Nurses described the ways in which they worked with each client to ensure that the programme's and the clients' goals were aligned in ways that reflected the programme's central philosophies.

Nurses discussed occasions where they found that they had to focus on issues they had not intended to address at that point - for example, if a client was experiencing a particular crisis which required them to adapt or change the intended content of the contact. However, for the most part, Family Nurses found that they were able to use and manipulate the programme materials in ways that made each session relevant for their client. With increasing knowledge and experience of the programme, they felt their ability to draw creatively on the materials to meet clients' needs had also increased.

…it's only now, with clients that are still pregnant, that I'm doing more of actually agenda-matching, and I couldn't have done it at the beginning. I couldn't have gone 'jump, jump, jump. Bring this. Bring that'. I think as you become more familiar with the programme, you're able to agenda-match with the clients' needs whilst covering the content that should be delivered, and that's only come with time, familiarity with the material, and hopefully some increased skill on my part.

[Family Nurse 6]

Delivery of a programme that was relevant and appropriate for each client and a structure that enabled them to work flexibly with clients was regarded by the Family Nurses as a critical factor underlying the success of the FNP programme. For example, early in the pregnancy phase of the programme, clients were provided with the opportunity to prioritise topics in terms of their own particular interests. Nurses felt that this process of agenda-matching enabled them to tailor the programme around each individual client.

It's got to be what they're wanting, what's going on in their life at that time, and let it flow from that.

[Family Nurse 3]

5.3 The involvement of others

Monitoring data shows that a third (34%) of visits were attended by the client's partner or the baby's father, while almost half (46%) were attended by at least one other person, usually a family member. In the next report, we will be able to include data from interviews with a client's nominated "significant other" (usually the partner or parent of the client). At this stage, however, we only have data from the Family Nurses and clients themselves on how others in their life have participated in the programme.

Clients reported that the Family Nurse had told them at the start that it was acceptable for a parent or partner to be involved in visits, but reported different levels of actual involvement in visits from their significant others. Some partners/fathers had not met the Family Nurse at all, either because of work commitments or because they were not at the client's house at the time of the visits. Another group of partner/fathers had met the Family Nurse once or twice, sometimes by chance because they happened to be at the client's house when the Nurse visited, or sometimes by design. Clients' reasons for the more limited involvement of their partners included work commitments, shyness on the part of their partner, or because the partner just did not want to get involved. Indeed, in some cases, clients reported that their partner would go out when he knew the Family Nurse was coming. Finally, there was a group of fathers who were very much involved and had attended several meetings with the Family Nurse, even if their actual participation in those meetings was sometimes limited.

Clients and Family Nurses commented that, even for fathers who were not particularly involved in visits, there were attempts to involve them in the programme as a whole. Clients reported that a copy of every sheet the Nurse gave them was left for their partner and that their partner would complete them, or do so together with the client. This was seen as "a nice thing" for the Nurse to do. Clients reported that they also fed back to their partner what the Nurse had said and, if there was a concern that topics might make the father or client self-conscious, the Nurses gave clients leaflets to give to their partner.

Clients valued their partner's involvement with FNP: it allowed him to receive new information, enabled them to do both their family trees and there was a view that it was helpful that the Nurse then knew both of them. Clients' perceptions were that the fathers liked having the Family Nurse as well.

Family Nurses reported that they had met a wide range of their clients' family and friends - including parents, siblings, grandparents and friends - although there were also some clients for whom the Family Nurse had not met any family members or friends. The actual extent of involvement in visits of all these family members was generally limited, with family members being "around" during meetings but not actively participating. Family Nurses were described as being accepting of and sensitive to other family members, but would always ensure that the client was comfortable with their presence. There were times though when the whole family would get involved. An example reported by a client was her family's excitement when a life-sized doll was brought in by the Family Nurse. Family members appeared to glean information as well, through being around while the Family Nurse was talking or through the client telling them what had been talked about:

"…everybody's sort o' learned bits and bobs like from her"

[Pregnancy Interview, Client 13]

In some cases, clients' mothers were very much involved with visits and would join in discussions. Those clients valued this, feeling that it made their mother feel more involved. Good relationships between the family Nurse and clients' mothers were reported. Indeed, one client reported that their mother had "taken a real shine to her"[Pregnancy Interview, Client 3]. There was also a view among clients that their mother's involvement in the FNP had brought them closer together.

5.4 Relationships between clients and Family Nurses

It was clear that clients experienced the programme via their relationship with their Nurse and that those experiences reflected the approaches and values which define FNP. It was evident from the client interviews how much they liked their respective Family Nurses, who were described as "really nice", "a good laugh", "funny", "friendly" and "great". It was suggested that talking to the Family Nurse was more like talking to a "pal" than a nurse or a midwife. In their pregnancy interviews, the qualitative panel of clients did not make any negative comments about their Family Nurses, with clients' accounts indicating that they got on "quite" or "really" well with their Nurse. Family Nurses were said to listen and help, both in terms of practical support, and in terms of helping to explain and clarify issues. Nurses were seen always to "add extra" [Pregnancy Interview, Client, 13].

Respondents reported that they found it easy to be open and honest with their Family Nurse and felt comfortable with them because they had built up a relationship and now trusted them. Confidentiality was key here, with clients reporting they were able to talk to their Family Nurse about anything because they knew it would be kept between the two of them, unless there were safety concerns. There was a view that Family Nurses gave balanced opinions and would never tell a respondent 'this is bad, this is good'. The Family Nurses were not seen as judgemental, but rather as being there to help.

Family Nurses were felt to be easy to talk to: they were perceived to have the time to sit and talk to clients in a way that midwives did not and to be open to any questions, even if they were not necessarily able to provide an immediate answer. The clients also felt that their Family Nurse did not make them talk about something if they did not want to. The sharing of experiences was valued.

Just sitting here with a cup of tea and a chit chat about anything and everything, just seems good.

[Pregnancy Interview, Client 14]

I feel quite comfortable telling her like pretty much anything, I've told her everything like, so it's like you're just speaking to a friend.

[Pregnancy Interview, Client 9]

While the clients in the qualitative panel reported good relationships with their Family Nurse at the time of their first interview for the evaluation, some clients reported that when they first enrolled with the programme they were not accustomed to opening up to other people and found this difficult to begin with. There was also a concern for some clients, at the start of the programme, that the Family Nurse might take their baby away if the client told them too much about their lives. Reassurances from Family Nurses about their role played an important part in allowing clients to build trust with their Nurse and also ensured that any disagreements or clashes of opinion could be addressed in a spirit of perceived compromise. Clients' accounts thus provide evidence of the developing therapeutic alliance with their Family Nurse.

Family Nurses expressed very similar views and experiences of this developing relationship as their clients. The frequency of visits during pregnancy was felt appropriate to building a relationship with clients. Also central to this was clients being able to trust their Nurse and know that she would visit as agreed. Nurses acknowledged that they did, on occasion, find it difficult to ask what might be deemed sensitive or intrusive questions - about issues such as income and domestic abuse - early in the client-Family Nurse relationship. There was a view that there was "a fine line" between gathering important but sensitive data and ruining the relationship. There was also a view that clients found some topics, such as sexual health, difficult to discuss at first, but that their own (that is, the Nurses') degree of comfort raising certain issues influenced clients' willingness to participate in discussions on potentially difficult topics.

The Nurses suggested that there was a balance too to be made between conveying information in visits and sounding like a teacher. Nurses were clear that the programme would not work if they came in and said - as one Nurse put it - ' right, this is what we're doing today'. The strengths-based approach of the programme - which recognises that clients have existing strengths and are capable of drawing on these to solve problems - may have helped convey that this was a different sort of relationship. Nurses also commented that a degree of humility was necessary on their part, whereby they would always acknowledge to clients if they could not answer a question.